All things considered, it’s not a bad time to be a baby. The newborn mortality rate in the U.S. has plummeted from nearly 20 per 1,000 births in the 1960s to the current rate of less than four per 1,000, according to the March of Dimes.

But the first month of life, when newborns are just starting to navigate the world outside the womb, is still by far the most vulnerable. The World Health Organization reports that in 2020, nearly half of the deaths of children under 5 worldwide occurred during the neonatal period: a baby’s first 28 days. About 10% of all infants need help breathing at birth, and approximately 1% need intensive resuscitation, according to the American Heart Association.

Resuscitating a newborn is very different from resuscitating an adult, however — or even a six-month-old. It can be hard for even the best-trained paramedics and EMTs to know exactly what to do with the tiniest of patients.

That’s why Tracie Dauwe, RN, a neonatal intensive care unit (NICU) nurse at Children’s Memorial Hermann Hospital, helped organize a new community program to give first responders hands-on training in neonatal resuscitation. “Paramedics don’t have access to this training — they learn pediatric life support, but those protocols are very different than they are for newborns,” she says. “And what we’ve seen in the past few years is more and more babies born outside the hospital, including preterm babies with serious health concerns. When something goes wrong with these babies, paramedics are typically the ones to reach them first.”

As a volunteer with the Southeast Texas Regional Advisory Council (SETRAC), a coalition of health care providers and first responders, Dauwe was instrumental in helping launch the council’s Neonatal Resuscitation Program for paramedics and EMTs throughout Houston. The first training session was held last October, drawing 28 first responders. A second session was held in March, and more are scheduled for the coming months.

The classes are taught by nurses from Memorial Hermann and other health systems — including Jennifer Wasson, RN, a NICU educator at Memorial Hermann Southwest Hospital.

“We were hearing from first responders that they didn’t feel as prepared for babies as for older kids. They don’t see them often, so when they do, they feel a little out of their element,” Wasson says. “It’s not that they don’t have the skills, but they don’t do this every day like we do in the NICU. They don’t have the practice or the confidence.”

It’s one thing to study neonatal resuscitation in a textbook, after all, and another to actually hold a newborn who isn’t breathing. That’s a harrowing experience that no one wants to have — but every first responder wants to be prepared for. And there are many reasons they might encounter a newborn in respiratory distress.

“It could be a baby who’s born outside the hospital, especially preterm, and had a complication that keeps them from breathing on their own,” says Wasson. “Or it could be a medical emergency in those first few weeks after birth, when the risk for SIDS, or sudden infant death syndrome, is highest. Maybe it’s a baby who picked up a respiratory virus, or maybe they were sleeping with a blanket or toy that blocked their airway. Back when my daughter was born, you’d get these bed sets for your baby, and you had a little mini comforter for the crib. Now we don’t recommend those, because as babies shift in their sleep, something like that — or a pillow or stuffed animal — can smother them.”

Resuscitating a newborn is very different from treating an older child or an adult who has suddenly stopped breathing. While pediatric and adult CPR begins with chest compressions to restart the heart, newborns rarely have cardiac events: the problem typically lies in their airway. So first responders will start by using a manual resuscitator to provide rescue breaths for babies who are not breathing or who are gasping for breath.

“Babies’ heart rates and respiratory rates are very different from ours. A pulse of 120 to 160 is about normal for a newborn. If it’s less than 100, we’ll start positive pressure ventilation — PPV. If it’s less than 60, we’ll also do chest compressions,” Wasson says. “But even if their heart rate is low, we’ll start with the airway, because if we can get them oxygenated and breathing well, even if we’re breathing for them, their heart rate generally will respond.”

Chest compressions also look much different on a newborn. Instead of pressing on a baby’s ribcage with their palms, NICU nurses use their thumbs. And there are other dangers unique to newborns, particularly preterm newborns. Hypothermia is a big one.

“Babies born at less than 32 weeks are at extreme risk for hypothermia, so monitoring birth temperature is absolutely essential,” Dauwe says. “With the first responders, we have to modify what we teach because they don’t have the specialized equipment we have in the hospital setting. We have to think about how to keep a preterm baby warm with the materials they have on hand. If they’re at someone’s home, can they put a towel in the dryer to warm it up? Or can the baby be transported on mom’s chest doing kangaroo care, with skin-to-skin contact? Do you have a plastic bag you can wrap the baby in? At the very least, you can turn up the heat in your vehicle.”

The training sessions, which are free for first responders, are already in such high demand that SETRAC is looking into ways to scale the program to include more of the region’s emergency medical services.

“We’re adding more and more classes to our schedule — it’s getting very big,” Dauwe says. “What’s great is that we don’t charge any of these EMS agencies for our time. If you have a room where we can hold the classes, we will be there.”

The feedback they’ve gotten from first responders who’ve taken the classes has been immensely positive. The end goal, of course, is to improve outcomes for newborns.

“We are working with our partners at SETRAC to develop tools to measure the program’s impact, but one thing is for certain: If you can keep these babies warm and keep them breathing until they get to the hospital, their chance of survival is drastically improved,” Dauwe says.

Giving first responders greater confidence also helps. “What’s great about this program is it’s four hours of hands-on skills, using every piece of resuscitation equipment we have in our toolbox. They can touch it, work with it, use it on a mannequin — and that helps build your confidence much more than reading about it in a book,” Wasson says. “When you actually practice it with your hands, it cements it in your mind.”

The good news is that knowledge of how to treat neonatal medical emergencies has come a long way, and the odds are improving even in worst-case scenarios. “We have advanced so much in the 20 years since I started as a NICU nurse,” Wasson says. “I’ve been to thousands of deliveries; I’ve resuscitated many, many times. As we’ve learned more about what works best, our outcomes are getting better and better.”

Being able to share that knowledge with first responders so they can use best practices in the field means that babies will be in better shape when they arrive at the ER, improving outcomes even further.

For more information, visit memorialhermann.org/services/specialties/childrens/nicu.